Provider Demographics
NPI:1659396554
Name:WILTS, MARILYN COMMERFORD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:COMMERFORD
Last Name:WILTS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3656
Mailing Address - Country:US
Mailing Address - Phone:510-233-1891
Mailing Address - Fax:
Practice Address - Street 1:419 KEARNEY ST
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3656
Practice Address - Country:US
Practice Address - Phone:510-233-1891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14688103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist